Discussion

Factors identified as determinants of unmet need have included access and quality of available health care services, health concerns about contraceptive use, social and familial opposition, especially from husbands, and a low perceived risk of pregnancy.1 5 6

The prevalence of unmet contraceptive need in this community-based study was 7.4%, which is lower than the level of 13% found in an area of similarly low socioeconomic level.7 However, it is similar to the national level (9.2%) found by the most recent Egypt Demographic and Health Survey (EDHS 2008).8

In this study, cases and controls were similar in almost all sociodemographic factors. No significant difference was noted between cases and controls as regards level of education, although many authors reported that less-educated women face more obstacles to using contraception.7 9 However, the EDHS 2008 revealed that generally the rate of unmet need remains relatively constant regardless of educational level.8 This may be due to comprehensive family planning services provided to the general public by the Ministry of Health in Egypt, which is able to deliver these services to a large segment of the population, irrespective of their socioeconomic status. Other investigators have reported that socioeconomic differentials in contraceptive use become smaller in countries where contraceptives are widely available and accessible.10

An important finding of this study was that cases were more likely to have a previous unwanted pregnancy than controls (OR 3.03, 95% CI 1.8–5.2). This finding agrees with that of Magadi, who reported that women who have experienced an unwanted birth are highly likely to have this repeated,11 and provides an opportunity for the identification of women with unmet need by health care providers.

Cases were less likely than controls to report that their main source of knowledge of family planning was from physicians. Other investigators have reported that non-users were less likely to have heard of family planning from a health care provider.12 Adhikari et al. found that women who had a higher level of knowledge about family planning methods were less likely to experience unintended pregnancy.3 This agrees with the present study as attending seminars on family planning was higher among the met need than the unmet need group.

Fear of experiencing adverse effects from contraception has been frequently reported as a reason for unmet need of contraception,7 8 13,–,16 Interviews in Egypt, Nepal, Pakistan and Zambia reveal that fear of the health side effects of contraceptives dissuades women from using a method, not only because of the physical complications, but also because of the expected time and financial costs of managing the side effects, the potential loss of labour productivity, the possibility of interference with spousal sexual relations and a sense that the side effects signify divine disapproval.16 In addition, our findings show that on multivariable logistic regression analysis, the strongest independent risk factor for unmet need was the respondent's actual previous experience of an adverse effect from contraceptive use. Experiencing menstrual side effects has a significant impact on contraceptive discontinuation,17 which may be later associated with an unmet contraceptive need due to fear of recurrence. Our study respondents with unmet need reported experiencing side effects due to injectable contraceptive and IUD use; this agrees with data from the EDHS 2008, where the highest rates of discontinuation among ever-users of contraceptives was for women who had experienced side effects due to either IUDs or injectable contraceptives.8 This actual experience of an adverse effect appears to be more important than fears of an adverse effect in influencing unmet need; it also gives health care providers a tangible method to identify women with a possible future unmet need, and with effective, appropriate counselling, to provide a suitable alternative method.

This study found that belief that contraception is religiously prohibited is a predictor of unmet need, consistent with results obtained in other Muslim countries.7 12 14 The Slow Fertility Transition Study of Egypt reported that almost 20% of respondents believed that religious leaders do not support family planning, believing it to interfere with God's will.5 Similarly, men in Pakistan also perceived that religious leaders are against family planning.18 This indicates the need for close co-operation between family planning programmes, religious authorities and the media, to emphasise the Islamic acceptance of contraceptive use to the public. It is advisable to involve local religious leaders as well, as community-level research has shown this to be an important means to improve the effectiveness of family planning programmes in communities.18

Deficient interspousal communication about contraceptive use and the desired number of children was an important risk factor for unmet need on multivariate analysis. Interestingly, on multivariate logistic regression, non-discussion of the desired number of children in the family was a more important risk factor for unmet need than disagreement on the number of the children. This suggests that recognition of this disagreement by women in this study enabled them to take the decision to postpone or limit childbearing. Non-discussion of family planning between husband and wife has been found to be associated with unmet need.19 Moreover, in some instances, husbands and wives have different perceptions of their unmet need,20 with wives believing that they have an unmet need while their husbands do not. Previous studies have shown that better interspousal communication is correlated with increased contraceptive use.12 19 21

Husband opposition is another important risk factor for unmet need. Some 21.3% of women with unmet need faced their husbands' opposition compared to only 6.3% of the met need group. This is repeatedly found in many different studies, in diverse cultures and countries such as Jordan, the Philippines, Rwanda and Honduras, as well as in Egypt.9 13 19 21 22

High levels of utilisation of, and satisfaction with, family planning health services were recorded among both cases and controls. This may be because in the small, urban district studied, with high provision of government-provided family planning services, little differences are found in the quality and accessibility of the health services available. Furthermore, literature exists demonstrating that unmet need is driven mainly by health concerns and societal opposition, rather than quality of services.13 22

In addition to other risk factors previously reported, our study findings showed that a high proportion of women with unmet need (73%) had actually used contraceptive methods previously, similar to the proportion of ever use in Egypt (79%).8 This indicates that many women with unmet need, at least at some point in their reproductive life, were willing to use contraceptives. In addition, a high proportion reported previously experiencing complications related to contraceptive use. This, as well as the data on previous unwanted pregnancy, confers health care providers with an important tool to identify women who are at risk of having a future unmet need. The study findings also indicate that concerted efforts should be directed by family planning programmes to men and to the general population to reduce their opposition to contraception use, and to assure them of the acceptability of family planning in Islam.